COVID-19 Immunization Screening and Consent Form

COVID-19 Immunization Screening and Consent Form
Date
MonthDayYear
Date
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date of Birth
MonthDayYear
Date
Age
Marital Status
Other
Insurance
Other
Have you participated in any COVID-19 Vaccine Trial?
Name of Vaccine

Screening

Rows	Yes	No
Have you been treated with antibody therapy for COVID-19 in the past 3 months?
Have you been exposed any person with COVID-19 in the past 14 days?
Have you been recommended by your physician to self-isolate for at least 14 days?
Have you been diagnosed to have COVID-19 in the past 3 months?
Have you ever had an allergic reaction such as hives or difficulty breathing, to any vaccines or shots?
Have you received any vaccine in the past 2-weeks other than for COVID-19?
Are you pregnant or planning to be pregnant?
Are you currently nursing or breastfeeding a child?
Do you have AIDS/HIV, cancer, leukemia or any condition that weakens the immune system?
Are you taking any medication that affect your immune system, such as chemotherapy drugs, cortisone, prednisone or other steroids, or undergoing radiation treatments?

By signing this form, I declare that the information I have provided above are true and correct to the best of my knowledge. I understand the risks involved in having the COVID-19 Vaccination. I understand that a COVID-19 vaccine requires two doses, with at least 20 days apart from each dose. In this regard, I shall ensure to comply with the scheduled dates for vaccination.
I have been given an opportunity to ask questions in relation to COVID-19 and the immunization, which answers were given to me to my satisfaction
I understand that it is my free prerogative to refuse or receive administration of the vaccine and all the consequences of the risks over this matter. In any case, I request that the COVID-19 vaccination be given to me
It is my responsibility to secure or determine whether my insurance policy covers the administration of the vaccine. In case not, I shall be responsible to pay for the costs in cash.
Finally, I authorize the release of my health information as needed for public health purposes, including for reportorial purposes for vaccine registry.
Signature
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